- Molina Healthcare (West Valley City, UT)
- …and Medicaid **Knowledge/Skills/Abilities** * Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and ... direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements… more
- Humana (Juneau, AK)
- …Director (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions regarding the appropriateness and… more
- Humana (Little Rock, AR)
- … Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and ... complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions about the appropriateness of services… more
- LA Care Health Plan (Los Angeles, CA)
- Customer Solution Center Appeals and Grievances Coordinator I (Temporary) Job Category: Administrative, HR, Business Professionals Department: CSC Appeals & ... achieve that purpose. Job Summary The Customer Solution Center Appeals and Grievances Coordinator I supports the...staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in… more
- Elevance Health (Mason, OH)
- …appeal and forwards to Medical Director for approval. + Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. + Documents ... **Nurse Appeals - Medicare ** **Location:** Virtual: This...skills and serves as a subject matter expert for appeals / grievances /quality of care issues and is a… more
- Commonwealth Care Alliance (Boston, MA)
- …5+ years of clinical nursing experience is strongly preferred. + Experience in Medicaid/ Medicare grievances and appeals and/or Utilization Review is strongly ... compliance with state and federal guidelines, including Centers for Medicare and Medicaid Services requirements. Maintain all appeals...Medical Director as needed. + Ensures that appeals and grievances are resolved timely to… more
- Commonwealth Care Alliance (Boston, MA)
- …of MassHealth and Medicare Advantage programs. Under the direction of the Director of Claims Operations and Quality Assurance, this role is responsible for the ... schedule issues. + Collaborate closely with Provider Relations, Contracting, Payment Integrity, Appeals & Grievances , and Configuration teams to validate and… more
- Sharp HealthCare (San Diego, CA)
- …to Plan policy as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care Manager to identify ... and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp Health Plan's (SHP)… more
- Excellus BlueCross BlueShield (Buffalo, NY)
- …on the Administration of BH QM/UM and performance improvement activities, including grievances and appeals . + Attendance at regular (at least quarterly) ... care system. + Develops, conducts concurrent and retrospective reviews of claims and appeals and resolves grievances related to medical quality of care, as… more
- Molina Healthcare (Racine, WI)
- …reviews and recommends corrective actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + ... medical necessity. + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the investigation of adverse… more
- Fallon Health (Worcester, MA)
- …NCQA standards, other applicable regulatory requirements and member expectations. The FH Member Appeals & Grievances Coordinator serves to administer the FH ... of Coverage, departmental policies and procedures, and regulatory standards. The Member Appeals & Grievances Coordinator serves as a liaison between FH… more
- Somatus (Mclean, VA)
- …provides guidance and oversight to all lines of business including Commercial, Medicaid, Medicare , and Special Need Plans (SNPs). The Director , Quality will work ... physical and mental well-being + Community engagement opportunities + And more! The Director of Quality, reporting to the AVP of Quality, is responsible for… more
- State of Colorado (Denver, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... clinic in a fiscally minded manner. Main contact with the DYS Medical Director for consultation and collaboration on individual cases. Oversees the general function… more
- Point32Health (Canton, MA)
- …including but not limited to P&T, DCC, MAD, Management team meetings, Appeals & Grievances , Quality Performance Improvement Team (QPIT). + Direct ... managing pharmacy costs. + Collaborate with the Pharmacy Medical Director and Marketing to develop member and provider specific...formularies) to meet unique plan requirements, ie, Centers for Medicare & Medicaid (CMS) & Health Care Reform (HCR).… more
- LA Care Health Plan (Los Angeles, CA)
- …care setting. Experience in health care auditing and monitoring (preferably in Appeals , Grievances , Quality Improvement, Utilization Management (UM) and so ... the Regulatory Compliance unit, the Advisor also advises and supports the Manager, Director , and Chief Compliance Officer on other duties as assigned to support the… more